Elsevier

Lung Cancer

Volume 44, Issue 3, June 2004, Pages 317-325
Lung Cancer

Comparison of whole-body FDG-PET to bone scan for detection of bone metastases in patients with a new diagnosis of lung cancer

https://doi.org/10.1016/j.lungcan.2003.11.008Get rights and content

Abstract

The purpose of this study was to compare the accuracy and agreement of whole-body positron-emission tomography (PET) scan to bone scintigraphy for the detection of bony metastases in staging patients with newly diagnosed lung cancer. The tumor registry and nuclear medicine database at our institution were queried and identified all patients between July 1998 and August 2002 with a new diagnosis of lung cancer, a whole-body 2-deoxy-2-[18F]fluoro-d-glucose (FDG)-PET scan, and a bone scan prior to therapy. All of these patients’ radiologic reports were then retrospectively reviewed, and confirmation of bone metastases was determined by consideration of all available clinical information. The sensitivity, specificity, and accuracy for each study were then calculated. Two hundred and fifty-seven patients fulfilled the entrance criteria. One hundred and four patients (40%) presented with stage IV disease, and bone metastases were confirmed in 57 (22%) patients. The accuracies of PET and bone scan were 94 and 85% (P<0.05), sensitivity values were 91 and 75%, and specificity values were 96 and 95%, respectively. The weighted-kappa statistic suggested moderate agreement between the two modalities (κw=0.510, 95% CI, 0.402–0.618). The use of both whole-body PET and bone scintigraphy as initial staging studies in lung cancer patients provides redundant information about the presence of bony metastases. The improvement in accuracy and sensitivity with PET suggests bone scan can be eliminated from the staging evaluation at presentation. Due to its retrospective nature, the results of this study are subject to several forms of bias including selection bias, verification bias, test review bias, and incorporation bias. A prospective trial with appropriate verification of bony metastases is suggested to confirm the results.

Introduction

Accurate staging of lung cancer is essential for patient management and in determining the optimal therapeutic strategy [1]. Clinical staging at the time of presentation is typically performed using a series of targeted diagnostic imaging studies including computed tomography (CT) of the thorax through the liver and adrenal glands, CT and/or magnetic resonance (MR) imaging of the head, and radionuclide bone scintigraphy (bone scan). More recently, whole-body 2-deoxy-2-[18F]fluoro-d-glucose (FDG) with positron-emission tomography (PET) has been suggested as an alternative study, which could provide a more accurate and efficient diagnostic approach than the combination of conventional imaging studies [2]. PET scanning has become an accepted tool for evaluation of regional lymph nodes, and some studies have shown it to be beneficial for extra-thoracic staging in the overall search of metastatic disease [3], [4], [5], [6]. More specifically, given the ability of PET to detect osseous metastasis, several small series have suggested that the high accuracy of PET may obviate the need for a bone scan [6], [7], [8], [9]. The purpose of this study was to compare the agreement and accuracy of PET scan to bone scans for the detection of distant bone metastases in patients with newly diagnosed lung cancer to determine if these were complementary or redundant studies.

Section snippets

Patient selection

The tumor registry and PET database at our institution were retrospectively reviewed to identify all patients with a pathologically proved new diagnosis of lung cancer and staging with both whole-body PET and bone scan prior to the initiation of therapy. Lung cancer patients at our institution routinely receive staging PET scans in the thoracic surgery clinic and staging bone scan in the thoracic oncology clinic. The review included 1100 patients with lung cancer diagnosed between July 1998 and

Patients

Lung cancer histology and stage distribution is listed in Table 1. One hundred and four (40%) of the 257 patients presented with stage IV disease, and 57 (22%) patients had osseous metastases by clinical–pathologic correlation.

PET scan

PET scan was considered positive for bone metastasis in 61 (24%) and negative in 196 (76%) patients. The sensitivity, specificity, and positive and negative predictive values of PET were 91% (95% CI, 81–97%), 96% (95% CI, 92–98%), 85% (95% CI, 74–93%), and 97% (95% CI,

Discussion

Once a new diagnosis of lung cancer has been established, an accurate assessment of the stage becomes crucial for deciding on treatment options and providing prognostic information. Conventional imaging studies are clearly less than optimal, as evidenced by the approximately 60% 5-year survival rates of patients initially diagnosed with early stage lung cancer [13]. These patients typically undergo curative resection, because there is no evidence for metastases, but almost 40% later recur with

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